Inspection on 04/07/07 for Queensway

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queensway 27/11/08

Queensway 17/10/06

Queensway 28/02/06

Queensway 05/10/05

Queensway 08/03/05

Queensway 29/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Grayling

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Queensway 46 Queensway Kirkburton Huddersfield West Yorkshire HD8 0SR Lead Inspector Cathy Howarth Key Unannounced Inspection 4th July 2007 10:00 Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queensway Address 46 Queensway Kirkburton Huddersfield West Yorkshire HD8 0SR 01484 602523 01484 428967 NO EMAIL 23/5/07 norfolkroad@st-annes.org.uk St Anne`s Community Services Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Stocks Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: Queensway is situated in a residential area of Kirkburton and offers nursing care for up to six service users with learning disabilities. The accommodation is on two floors, four bedrooms on the first floor and two bedrooms on the ground floor. Rooms are single occupancy and do not have en-suite facilities. There is a bathroom and toilet on both the ground floor and first floor. Communal areas are of a domestic nature and furnished to a good standard. The home has its own transport, two vehicles, that service users contribute towards. Fees at the home on the day of this inspection were said to be £440. 28 Items not covered by fees include holidays and toiletries. There is a Service user Guide available, which gives information about the home and inspection reports by the Commission for Social Care Inspection are also available from the home on request. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out using information provided by the manager before the site visit. The inspector also sent surveys out to all six people living at the home and to relatives and other professionals who have a connection with the people living there. No surveys were returned from people living at the home. Four relatives responded and one GP also made comments. The surveys that were returned indicate that relatives hold a very positive view of the service provided. The site visit took place over a period of nine hours from 10am until 7pm. During this visit the inspector met with people living at the home, talked with staff and the manager and observed life within the home. A meal was also shared with people living there. Overall this inspection was fairly positive. The lifestyles of service users were seen to be generally good and the atmosphere within the home was friendly and relaxed. There were some improvements that were needed in management and operation of the service however. The inspector would like to thank all the people living and working at Queensway for their welcome and co-operation throughout this inspection. What the service does well: Information for people living at the home about what they can expect from the service is adequate but could be significantly improved. People living at Queensway are well supported in having their needs met and to take risks to lead fulfilling lives. People living at Queensway have good life opportunities for enjoyment fulfilment and personal development. The design and layout of the home supports people living at Queensway to live in a clean, well-maintained and comfortable environment. People living at Queensway are supported by a skilled and committed team People living at Queensway are generally well supported in meeting their health and personal care needs. The home is generally well managed in the interests of the people living there. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People who use the service experience adequate quality outcomes in this area. Information for people living at the home about what they can expect from the service is adequate but could be significantly improved. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The service has a Statement of Purpose and a Service User guide. Each individual has a copy of the Guide in their personal files, and includes a copy of the complaints leaflet. Both these documents need to be updated to reflect the changes in the service and changes in such things as address of the local Commission for Social Care Inspection office. There should be clearer information for people on how to raise issues and also a more user-friendly format would be helpful. As people living at Queensway have been there for many years, admission assessments were not relevant. More recently, Person Centred Planning has enabled carers to revisit people’s needs however and this is discussed in more detail in the next section. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. People living at Queensway are well supported in having their needs met and to take risks to lead fulfilling lives. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The service has adopted the Person Centred Planning (PCP) approach to planning care for individual. This seeks to involve the individual as much as possible and to consider maximising each individual’s life opportunities. Two of these were examined as part of this inspection. Both considered the person’s life holistically and included hopes and aspirations and known factors that enhance individual well being, such as relationships with key people, hobbies and interests, self help skills and health issues. Both plans seen were detailed and informative. They both included action plans for making sure that the elements identified as important for each person were acted upon and progress was recorded. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 10 It was not clear from the plans how much direct involvement people living at the home had in drawing up the plans. One staff member who had taken part in developing the plans indicated that this was limited and relied on staff’s knowledge and observation of the individuals. This could be improved through better use of communication supports and any involvement should be specifically recorded. In fact this was one area that appeared to be underdeveloped within the plans seen. A specific section detailing ways of communicating and addressing ways of improving this between staff and the individual is an area that could be improved within the home. Plans included details of risk assessments, which help to show how individuals are to be supported in situations where they may be at risk or present risks to others. These were positive and emphasised enabling people to be involved in activities rather than preventing their participation. However there are several restrictions in place around the home for the safety of people living there, such as a lack of soap and towels in bathrooms, child locks on cupboard doors and the bin being locked in a cupboard. These need to be clearly documented as to the reasons for these and should be reviewed regularly to ensure the need for them is still applicable and alternative methods that do not restrict every person for the sake of one or two individuals should also be sought. Relatives who responded to the survey were unanimous in the view that individual needs were met by the service. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. People living at Queensway have good life opportunities for enjoyment fulfilment and personal development. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: People living at Queensway have a range of opportunities for participation in leisure activities and holidays. On the day of the inspection visit two people were away on holiday in Northumberland and it was clear that annual holidays are a popular feature of life at the home. Details of people’s wishes for their lifestyle were clearly detailed in the Person Centred Plans for individuals and it was noted from daily records that staff do their utmost to facilitate these activities and to promote the development of skills that enable people to gain self confidence and enjoyment in their lives. For example the plans detail how people will keep in touch with family and Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 12 friends that are important to them. One file did have a goal to meet with relatives and a brother but the goal in relation to the brother appeared not to have been recorded as met. One relative also mentioned that they would like to have more frequent visits if it could be managed and to meet up with other family members. Where individuals have spiritual needs these are catered for. For example one person attends church every week supported by friends. People living at Queensway are known locally and part of the small local community having been living there for some twenty years. Food is an important part of life. Menus at Queensway are prepared with healthy eating options in mind, offering ‘five a day’ to people as far as possible. Fresh fruit and vegetables feature every day and were seen to be available on request and staff were seen to offer this frequently to people. It is disappointing that such things are not readily available for people to help themselves. This was explained in terms of the propensity of certain individuals to gorge themselves and therefore the food is restricted for health reasons. Relatives who commented on people’s lifestyles were mostly positive about how people are encouraged to follow their interests and to do a range of activities. One relative commented: “he has his interests and preferences thoughtfully met.” Another commented that the home does well at “everything, outings, holidays, going out for meals, looked after well and clean clothes every day.” Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience adequate quality outcomes in this area. People living at Queensway are generally well supported in meeting their health and personal care needs but improvements need to be made in managing medicines. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: Each person living at Queensway has a support plan which includes details of how the prefer to be supported for personal care tasks such as bathing and outlines their individual routines for day and night time such as how they like to be got up and bed time routines. These plans also include a health action plan for each person based on a health assessment document that identifies areas of need. These plans were found to be generally good and staff record and keep appointments for such things as optician visits, dental visits, chiropody and specialist appointments. This area was found to be good. There was also evidence on files that medication reviews were taking place. A GP responded to the survey sent, saying that staff support individuals well to attend appointments and request reviews appropriately. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 14 One area that needs some attention however was around the management of medication. In the medication files there was a fair amount of old sheets and guidance, which was outdated. For some individuals there was no guidance for staff around when and why ‘as required’ medication should be given. This is very important and must be improved for the safety of people living at Queensway. Stock balances on the medication (MAR) sheets were found to tally with stock held but there had been one shift when no medication had been signed for on 2 July. Some medicine prescribed for one person to be used in an emergency for seizures, was not recorded on any sheet. The manager said it had been prescribed some time ago but a decision had been taken that it was not suitable for the person concerned and the pharmacist had refused to have it returned as it had been dispensed elsewhere. This medicine needs to be removed from the premises if it is not to be used. Staff informed the inspector that they are currently checking stocks of medicines on each shift, which involves two staff for approximately half an hour at each handover. This could be up to 3 hours per day of staff time devoted to this task. The home does not currently use a monitored dose system, but this should be considered in order to free up staff time from this task. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience adequate quality outcomes in this area. People living at Queensway are largely safeguarded from harm but staff training is needed to ensure that no one is at risk from poor handling in a crisis situation. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: St Anne’s has a complaints procedure, which is open to anyone including relatives of people using the service to use. All relatives but one indicated in surveys that they were aware of how to raise concerns. People living at the home would need support to do this themselves. Copies of this procedure were found on people’s files along with the service user guide. The leaflet needed amendments to reflect the change of location and telephone number of the local Commission for Social Care Inspection office. No complaints have been received since the last inspection and all relatives who responded, indicated that they were very satisfied with the service. One relative said; “I am always secure in my mind that X is safe and happy and being well cared for. For this I am grateful to all those who make it so.” None of the people living a the home use advocates at the present time, although most have close relatives who can speak for them should this be needed. One person unfortunately does not have anyone to fulfil this role, Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 16 however. It is therefore recommended that an advocate is found to protect this person’s interests and to ensure that they have an independent voice. Staff at the home are given training in safeguarding vulnerable adults as part of their induction and foundation training. It would be helpful to ensure this is updated regularly to ensure people are completely aware of their duties in safeguarding the people living at Queensway. One area for improvement is in ensuring that staff are trained to physically intervene to protect people when this is necessary. Staff meeting minutes indicated that this training has been requested for some time but has not yet taken place. The manager stated that training in techniques that are safe for both people living there and staff is planned for July but no dates had yet been confirmed. This needs to be a priority as at least one person’s plan indicates that this may be necessary at certain times. There have been two safeguarding referrals in the last few months at the home. The handling of these was done according to local procedures for safeguarding and investigations concluded that there was no evidence of any harm to people living at the home. There have however been recommendations made in terms of some areas of management, staff training and practice, some of which are reflected within this report. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 People who use the service experience good quality outcomes in this area. The design and layout of the home supports people living at Queensway to live in a clean, well-maintained and comfortable environment. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The environment at Queensway is homely, clean and well maintained. Since the last inspection the front entrance way has been decorated and a new carpet has been fitted in the lounge. There is a rolling programme for renewal of decorations. The inspector saw three bedrooms as part of this visit, all of which were decorated in bright colours and reflected the interests of the occupants. Communal areas were also bright and homely. The dining room is awaiting new chairs as most of the old ones have been broken, so garden furniture was Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 18 in use at the time of this visit. There was a piano which one person likes to play and an organ as well as the usual TV and music players. Relatives who commented on the home said they found it pleasant, one person said: “It feels like a real home – never a hint of institutionalism” One person has a key for their bedroom door but all others do not. One person has a mortice lock on their door as it used to be the office some time ago. This lock should be removed as it is not suitable and prevents the door from working effectively as a fire door. It is recommended that all bedrooms are fitted with locks to protect people’s private possessions when they are out of the building as staff did say that some people do go in other people’s bedrooms. The laundry is sited on the first floor to make it easily accessible from bedrooms and so that soiled laundry does not generally need to be taken through communal areas. It was found to be suitable for the small group living at the home. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use the service experience adequate quality outcomes in this area. People living at Queensway are generally supported by a skilled and committed team, but some improvements are needed to ensure continuity of care and some core skills are still needed for staff to work safely with some people. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: Queensway provides nursing care and therefore always has qualified staff on duty each day. The manager is also a qualified nurse, bringing the number of qualified staff to seven out of the fourteen working on a permanent basis in the home. . Support workers are unqualified but are given induction and foundation training to equip them to meet the needs of individuals under the guidance of a nurse. Staff records show that staff do have good training opportunities, although there are some significant gaps as noted earlier in the section on concerns, complaints and protection. Staff have the opportunity to gain NVQ qualifications also, although only one person has achieved this. Relatives who responded to the surveys indicated that they felt that staff are well qualified and carry out their duties well. One person said: Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 20 “I am always impressed with their skills and knowledge, always applied with care and sensitivity.” One relative did however raise a slight concern about “new staff coming and going on a regular basis.” Agency staff are used in the home to cover vacancies and emergencies such as sickness. The manager stated that they try to get the same people who know the people living there but this is not always possible. The length of time taken to recruit new staff was said to be a problem resulting in having to use agency cover. Staff recruitment is carried out according to St Anne’s policy and procedure and is largely handled by the Human Resources Department. Staff records were not found at the home. There should be a pro-forma as agreed with the Commission for Social Care Inspection but this was not available. Nor were there any records relating to agency staff who may work at the home. These details need to be kept in the home as a basic reference to evidence that checks have been carried out on any workers in the home. Staff meetings were said to be held approximately monthly. However the minutes available only indicated that two have been held in 2007. Similarly staff supervision was found to be out of date. Staff appraisals have been held annually but regular formal supervision not as regular as recommended with some staff supervision records not showing any for over a year Staffing levels at the home are adequate generally. On the day of this visit staffing levels were good because two people were away on holiday so there were three staff available to meet the needs of four people, one of which was at day centre. Staff took this opportunity to go out with one person shopping ready for his birthday. Staff said that it is more difficult at times when there are only two staff to meet the needs of six people, generally at weekends. Given that one person needs two staff to supervise them while out of the home, this makes going out difficult sometimes. The result is that everyone goes out together or not at all, which affects people’s opportunities and choices. It is recommended that there should always be three staff on at weekends when all the people living there are generally at home. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. The home is generally well managed in the interests of the people living there. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The manager of the home is qualified and competent to manage the home and has done so for a number of years. St Anne’s operates an annual quality assurance system, which seeks to identify areas for improvement and to build on success. This includes seeking feedback from people suing the service and their relatives. Outcomes of Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 22 person centred plans also inform how improvements may be made. The home has an action plan following from this, which identifies where their focus is for the year. The manager said he was in the process of developing the plan for this year. From last year’s plan it appears that some goals have been met while others are still outstanding. The plan itself is not a particularly robust document and would benefit from being written with more measurable goals and clear monitoring arrangements. St Anne’s have also gained the Investors in People Award. Health and Safety systems within the home are generally good. Tests of equipment including fire, gas and electrical systems were up to date. The maintenance man was testing portable appliances on the day of this visit. The system for reporting and getting repairs done appears to work well and is reflected in the generally good condition of the environment found in the home. One area for development is in fire training for staff, which was also required at the last inspection. It is important that ALL staff have training and participate in at least two drills each year so that they are familiar with what is required of them in the event of a fire. Two drills have been held in the last year but only seven staff have taken part. Some staff have taken part in both and some newer staff have not yet had the opportunity to participate in a drill at all. Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The arrangements for the management of medicines, and especially for guidance for staff in the use of ‘as required’ medicines must be improved for the safety of people living at the home. All staff working at the home must be trained in safe methods of physical intervention if they are likely to be required to use this. The mortice lock on one person’s bedroom door must be removed to ensure the door functions effectively as a fire door. Records relating any staff working at the home including their recruitment must be available for inspection. All staff must participate in a fire drill at least twice a year. Timescale for action 31/07/07 2 YA23 13(6) 31/07/07 3 YA24 23(4) 31/07/07 4 YA34 17(2) 31/07/07 5 YA42 23(4) (d, e) 30/09/07 Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard YA6 YA6 YA9 Good Practice Recommendations The involvement of individuals in the development of their person centred plans should be recorded. The plans should include details of how individuals express their wishes and desires and have goals for developing these. Restrictions on individuals or on the whole group should be regularly reviewed with the aim of removing restrictions wherever possible. The named individual who has no close family should have an advocate to ensure they have an independent voice separate from the organisation. Locks should be fitted to all bedroom doors to protect people’s personal possessions. It is recommended that staffing levels should be a minimum of three at weekends when all the people living there are at home, so that their choices of activities are not defined by staffing levels. Care staff should receive formal documented supervision at least six times a year. Team meetings should also be held more frequently. All staff should have two fire lectures and drills a year. YA22 5 6 YA26 YA33 7 YA36 8 YA42 Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queensway DS0000001125.V343871.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!